Disadvantaged Americans are suffering the brunt of rising pain and physical limitations.

Using data from three national surveys of US adults (one cohort and two cross-sectional studies, covering the period from the mid-1990s to the mid-2010s), we quantify the degree to which disparities by socioeconomic status (SES) in self-reported pain and physical limitations widened and explore whether they widened more in midlife than in later life. Unlike most prior studies that use proxy measures of SES (e.g., education), we use a multidimensional measure of SES that enables us to evaluate changes over time in each outcome for fixed percentiles of the population, thereby avoiding the problem of lagged selection bias. Results across multiple datasets demonstrate that socioeconomic disparities in pain and physical limitations consistently widened since the late 1990s, and if anything, widened even more in midlife than in late life (above 75). For those aged 50-74, the SES disparities in most outcomes widened by more than 50% and in some cases, the SES gap more than doubled. In contrast, the magnitude of SES widening was much smaller above age 75 and, in the vast majority of cases, not significant. Pain prevalence increased at all levels of SES, but disadvantaged Americans suffered the largest increases. Physical function deteriorated for those with low SES, but there was little change and perhaps improvement among the most advantaged Americans. At the 10th percentile of SES, the predicted percentage with a physical limitation at age 50 increased by 6-10 points between the late-1990s and the 2010s, whereas at the 90th percentile of SES, there was no change in two surveys and in the third survey, the corresponding percentage declined from 31% in 1996-99 to 22% in 2016-18. The worst-off Americans are being left behind in a sea of pain and physical infirmity, which may have dire consequences for their quality of life and for society as a whole (e.g., lost productivity, public costs).

Racial and ethnic variations in caregiving-related physical, emotional, and financial strain during COVID-19 among those caring for adult cancer patients.

PURPOSE: Cancer caregiving is shown to be a burdensome experience in typical times. The purpose of this study was to describe cancer caregivers' emotional, physical, and financial strain during the COVID-19 pandemic and compared to preCOVID-19, and explore racial and ethnic variations in caregiver strain. METHODS: We conducted a cross-sectional online survey using Lucid, LLC, incorporating quotas for race, ethnicity, gender and age. Caregivers had to be adults living in the USA and currently providing unpaid care to an adult cancer patient (i.e., during COVID-19) and prior to the pandemic. We assessed the caregivers' emotional, physical, and financial strain and asked them to compare to preCOVID-19 caregiving. Analyses included descriptive and linear regression adjusting for sociodemographic and caregiving-related variables. RESULTS: A total of 285 caregivers met eligibility, and most were nonHispanic white (72.3%) and female (59.6%). Based on a scale of "1: Much lower" to "5: Much higher", the financial, physical and emotional strain/stress experienced by caregivers compared to preCOVID-19 was, on average, 3.52 (SD: 0.82; range: 1-5) for financial strain, 3.61 (SD: 0.86; range: 1-5) for physical strain, and 3.88 (SD: 0.89; range: 1-5) for emotional stress. NonHispanic black caregivers were significantly more likely than nonHispanic white caregivers to indicate that caregiving-related financial strain was higher than preCOVID-19. Moreover, Hispanic caregivers compared to nonHispanic white caregivers reported caregiving-related emotional stress was higher than preCOVID-19. CONCLUSION: These findings suggest a need to be attentive to racial and ethnic variations in emotional and financial strain and provide targeted support in clinical care and via public policy during a public health crisis.

Health-Related QOL and Economic Burden of Chronic Pruritus.

Chronic pruritus (CP) has considerable implications for QOL. However, its impact on health-related QOL and economic burden is not fully characterized. We administered a cross-sectional survey on 132 patients with CP using the Health Utilities Index Mark 3 instrument. Normative data from healthy adults (n = 4,187) were obtained from the Joint Canada/US Survey of Health. Quality-adjusted life-year loss and economic costs were estimated on the basis of Health Utilities Index Mark 3 scores of patients with CP versus controls. Patients with CP had lower overall health performance than the control (0.56 ± 0.03 vs. 0.86 ± 0.003, P < 0.001). In multivariable regression, CP was associated with worse overall health performance (coefficient = -0.30, 95% confidence interval = -0.33 to -0.27), most accentuated in the domains of pain (coefficient = -0.24, confidence interval = -0.28 to -0.21) and emotion (coefficient = -0.11, confidence interval = -0.13 to -0.10). The reduced Health Utilities Index Mark 3 score correlated with 5.5 average lifetime quality-adjusted life-years lost per patient. Using conservative estimates for willingness to pay, the quality-adjusted life-year loss translated to an individual lifetime economic burden of $274,921 and a societal burden of $88.8 billion. CP is associated with significant QOL impairment. The economic burden of CP highlights the necessity for further research into management options.

Disease burden on health care by pain severity and usual analgesic treatment in patients with symptomatic osteoarthritis: a Spanish nationwide health survey.

BACKGROUND: Osteoarthritis (OA) pain is a health care highly demanding and costing condition. OBJECTIVE: To estimate disease burden on health care in OA in Spain, determining whether burden differs by pain severity and usual analgesic treatment. METHODS: A cross-sectional design using the 2017-Spanish-National-Health-Survey was used to abstract data of 5,234 adult patients (women 70.8%; 69.9 years) with a self-reported physician OA diagnosis. Patients were assembled according to pain severity (no/mild, moderate, severe) and use of usual analgesia (treated [66.5%]/untreated). Healthcare resource utilization (HRU) and corresponding costs were expressed Per-Patient-Per-Year (PPPY) and adjusted for covariates. RESULTS: Average (SD) healthcare cost was €2,274 (5,461) PPPY, with costs linked to outpatient medical visits being the major driver; ~43%. Adjusted PPPY medical visits, days of hospitalization, other healthcare visits, and corresponding costs were significantly higher in severe pain OA patients, compared to moderate or mild/no pain regardless of being currently treated with usual analgesics or not (p < 0.001). Treated OA patients showed higher HRU and costs than untreated patients. CONCLUSIONS: Severity of pain was the main driver of HRU and costs in OA patients from a nationwide representative survey in Spain. These findings seem to be more consistent in treated versus not treated patients with usual analgesics.

Effects of pain, sedation and delirium monitoring on clinical and economic outcome: A retrospective study.

BACKGROUND: Significant improvements in clinical outcome can be achieved by implementing effective strategies to optimise pain management, reduce sedative exposure, and prevent and treat delirium in ICU patients. One important strategy is the monitoring of pain, agitation and delirium (PAD bundle). We hypothesised that there is no sufficient financial benefit to implement a monitoring strategy in a Diagnosis Related Group (DRG)-based reimbursement system, therefore we expected better clinical and decreased economic outcome for monitored patients. METHODS: This is a retrospective observational study using routinely collected data. We used univariate and multiple linear analysis, machine-learning analysis and a novel correlation statistic (maximal information coefficient) to explore the association between monitoring adherence and resulting clinical and economic outcome. For univariate analysis we split patients in an adherence achieved and an adherence non-achieved group. RESULTS: In total 1,323 adult patients from two campuses of a German tertiary medical centre, who spent at least one day in the ICU between admission and discharge between 1. January 2016 and 31. December 2016. Adherence to PAD monitoring was associated with shorter hospital LoS (e.g. pain monitoring 13 vs. 10 days; p<0.001), ICU LoS, duration of mechanical ventilation shown by univariate analysis. Despite the improved clinical outcome, adherence to PAD elements was associated with a decreased case mix per day and profit per day shown by univariate analysis. Multiple linear analysis did not confirm these results. PAD monitoring is important for clinical as well as economic outcome and predicted case mix better than severity of illness shown by machine learning analysis. CONCLUSION: Adherence to PAD bundles is also important for clinical as well as economic outcome. It is associated with improved clinical and worse economic outcome in comparison to non-adherence in univariate analysis but not confirmed by multiple linear analysis. TRIAL REGISTRATION: clinicaltrials.gov NCT02265263, Registered 15 October 2014.

The prevalence and economic burden of pain on middle-aged and elderly Chinese people: results from the China health and retirement longitudinal study.

BACKGROUND: To estimate the prevalence of pain among people aged 45 years and older in China, to analyze the effect factors of pain and pain related economic burden. METHODS: Nationally representative sample was derived from China Health and Retirement Longitudinal Study (CHARLS). Pain data, medical cost data were obtained, as well as information of demographic characteristics, social structure, social-economic status, other health needs and health behaviors. The prevalence of pain in 2011, 2013, and 2015 was calculated. Univariate analysis and multivariate analysis were used to find the effect factors of pain. An optimization two-part model was used to calculate the range of the direct medical costs caused by pain. RESULTS: The prevalence of pain among people 45 years or older in China was 31.73% in 2011, 37.27% in 2013 and 28.62% in 2015. When evaluating factors lead a higher prevalence of pain, the results of the multi-variable after one-way analysis were older age, female, lower education, rural residents, without insurance status, abstained from alcohol and lower body mass index (BMI). Through the optimization of two-part model, the direct medical costs caused by pain was 898.9-1563.0 yuan in 2011, 2035.8-2568.7 yuan in 2013 and 2628.8-3945.7 yuan in 2015 (129.9US$ - 225.9US$ in 2011, 294.2 US$ - 371.2US$ in 2013 and 379.9US$ - 570.2US$ in 2015, converted to 2010 RMB). CONCLUSION: The prevalence of pain among middle-aged and elderly Chinese is high. Residents with older age, female, lower education, rural residents, without insurance status, abstained from alcohol and lower BMI seem to have a higher pain prevalence. Pain can cause extra direct medical costs and will cause more economic loss with the progress of time. Future research should pay more attention to effective treatment, management and prevention of pain to decrease its burden.

Cost-effectiveness of the Collaborative Care to Preserve Performance in Cancer (COPE) trial tele-rehabilitation interventions for patients with advanced cancers.

PURPOSE: The purpose of this analysis was to determine the cost-effectiveness of a Collaborative Care Model (CCM)-based, centralized telecare approach to delivering rehabilitation services to late-stage cancer patients experiencing functional limitations. METHODS: Data for this analysis came from the Collaborative Care to Preserve Performance in Cancer (COPE) trial, a randomized control trial of 516 patients assigned to: (a) a control group (arm A), (b) tele-rehabilitation (arm B), and (c) tele-rehabilitation plus pharmacological pain management (arm C). Patient quality of life was measured using the EQ-5D-3L at baseline, 3-month, and 6-month follow-up. Direct intervention costs were measured from the experience of the trial. Participants' hospitalization data were obtained from their medical records, and costs associated with these encounters were estimated from unit cost data and hospital-associated utilization information found in the literature. A secondary analysis of total utilization costs was conducted for the subset of COPE trial patients for whom comprehensive cost capture was possible. RESULTS: In the intervention-only model, tele-rehabilitation (arm B) was found to be the dominant strategy, with an incremental cost-effectiveness ratio (ICER) of $15 494/QALY. At the $100 000 willingness-to-pay threshold, this tele-rehabilitation was the cost-effective strategy in 95.4% of simulations. It was found to be cost saving compared to enhanced usual care once the downstream hospitalization costs were taken into account. In the total cost analysis, total inpatient hospitalization costs were significantly lower in both tele-rehabilitation (arm B) and tele-rehabilitation plus pain management (arm C) compared to control (arm A), (P = .048). CONCLUSION: The delivery of a CCM-based, centralized tele-rehabilitation intervention to patients with advanced stage cancer is highly cost-effective. Clinicians and care teams working with this vulnerable population should consider incorporating such interventions into their patient care plans.

Financial difficulties are associated with greater total pain and suffering among patients with advanced cancer: results from the COMPASS study.

BACKGROUND: The Universal Health Coverage goals call for access to affordable palliative care to reduce inequities in "total pain" and suffering. To achieve this, a patient-centred understanding of these inequities is required. AIM: To assess association of total pain and suffering (i.e. physical, psychological, social, and spiritual health outcomes) and perceived health care quality with financial difficulties among stage IV solid malignancy patients. DESIGN: Using baseline data from the COMPASS cohort study, we assessed total pain and suffering including physical (physical and functional well-being, pain, symptom burden), psychological (anxiety, depression, emotional well-being), social (social well-being), and spiritual (spiritual well-being, hope) outcomes and perceived health care quality (physician communication, nursing care, and coordination/responsiveness). Financial difficulties were scored by assessing patient perception of the extent to which their resources were meeting expenses for their treatments, daily living, and other obligations. We used multivariable linear/logistic regression to test association between financial difficulties and each patient-reported outcome. SETTING/PARTICIPANTS: Six hundred stage IV solid malignancy patients in Singapore. RESULTS: Thirty-five percent reported difficulty in meeting expenses. A higher financial difficulties score was associated with worse physical, psychological, social, spiritual outcomes, and lower perceived quality of health care coordination and responsiveness (i.e. greater total pain and suffering) (all p < 0.05). These associations persisted after adjustment for socio-economic indicators. CONCLUSION: Results identify advanced cancer patients with financial difficulties to be a vulnerable group with greater reported total pain and suffering. A holistic patient-centred approach to care at end-of-life may help meet goals for Universal Health Coverage.

The association of pain interference and opioid use with healthcare utilization and costs, and wage loss among adults with osteoarthritis in the United States.

Aim: To examine associations of opioid use and pain interference with activities (PIA), healthcare resource utilization (HRU) and costs, and wage loss in noninstitutionalized adults with osteoarthritis in the United States (US). Methods: Adults with osteoarthritis identified from the Medical Expenditure Panel Survey for 2011/2013/2015 were stratified by no-opioid use with no/mild PIA, no-opioid use with moderate/severe PIA, opioid use with no/mild PIA, and opioid use with moderate/severe PIA. Outcomes included annualized total HRU, direct healthcare costs, and wage loss. Multivariable regression analyses were used for comparisons versus no-opioid use with no/mild PIA (referent). The counterfactual recycled prediction method estimated incremental costs. Results reflect weighted nationally representative data. Results: Of 4,921 participants (weighted n = 20,785,007), 46.5% had no-opioid use with no/mild PIA; 23.2% had no-opioid use with moderate/severe PIA; 9.6% had opioid use with no/mild PIA; and 20.7% had opioid use with moderate/severe PIA. Moderate/severe PIA and/or opioid use were associated with significantly higher HRU and associated costs, and wage loss. Relative to adults with no/mild PIA, opioid users with moderate/severe PIA were more likely to have hospitalizations, specialist visits, and emergency room visits (all p < .001). Relative to the referent, opioid use with no/mild PIA had higher per-patient incremental annual total healthcare costs ($11,672, 95% confidence interval [CI] = $11,435-$11,909) and wage loss ($1,395, 95% CI = $1,376-$1,414) as did opioid use with moderate/severe PIA ($13,595, 95% CI = $13,319-$13,871; and $2,331, 95% CI = $2,298-$2,363) (all p < .001). Compared with the referent, estimated excess national total healthcare costs/lost wages were $23.3 billion/$1.3 billion for opioid use with no/mild PIA, and $58.5 billion/$2.2 billion for opioid use with moderate/severe PIA. Limitations: Unobservable/unmeasured factors that could not be accounted for. Conclusions: Opioid use with moderate/severe PIA had significantly higher HRU, costs, and wage loss; opioid use was more relevant than PIA to the economic burden. These results suggest unmet needs for alternative pain management strategies.

Impact of Pain Severity and Opioid Use on Health Care Resource Utilization and Costs Among Patients with Knee and Hip Osteoarthritis.

BACKGROUND: Osteoarthritis (OA) is the most common form of arthritis. The primary symptom of OA-pain-increases the disease burden by negatively affecting daily activities and quality of life. Opioids are often prescribed for treating pain in patients with OA but have questionable benefit-risk profiles. There is limited evidence on the economic impact of pain severity and opioid use among patients with OA. OBJECTIVES: To (a) evaluate the association of pain severity with health care resource utilization (HRU) and costs among patients with knee/hip OA and (b) characterize the association of opioid use with HRU and costs while controlling for pain severity. METHODS: Using deterministically linked health care claims data and electronic health records from the Optum Research Database, this retrospective cohort study included commercial and Medicare Advantage Part D enrollees who were diagnosed with knee/hip OA during the January 1, 2010-December 31, 2016 time period and had ≥ 1 pain score (11-point Likert scale: 0 = no pain, 10 = worst possible pain) between the first OA diagnosis date and October 2016. The index date was the date of the evaluated pain score; HRU and costs were observed over the 3-month postindex period. For patients with multiple pain scores, each episode required a 3-month post-index follow-up period. Generalized estimating equation models, adjusted for multiple observation panels per patient and baseline variables that may contribute to HRU and costs (age, sex, race/ethnicity, region, insurance type, integrated delivery network, body mass index, pain medication use, provider specialty, Charlson Comorbidity Index score, and other select comorbid conditions), were used to estimate all-cause and OA-related costs expressed as per patient per month (PPPM). Comparisons were performed for moderate (score 4-6) and severe (score 7-10) pain episodes versus no/mild pain episodes (score 0-3) and those with baseline opioid use versus those without. RESULTS: Included were 35,861 patients with knee/hip OA (mean age 66.5 years; 64.7% women) who had 70,716 pain episodes (58% mild, 23% moderate, 19% severe, and 37.0% with baseline opioid use). When controlling for other potential confounding factors, moderate/severe pain episodes were associated with higher all-cause and OA-related HRU than mild pain episodes. Relative to mild pain episodes, moderate/severe pain episodes were also associated with significantly higher adjusted average all-cause PPPM costs ($1,876/$1,840 vs. $1,602), and OA-related PPPM costs ($550/$577 vs. $394; all P < 0.05). Baseline opioid use was associated with significantly higher all-cause PPPM costs versus no opioid use (mild, $1,735 vs. $1,492; moderate, $2,034 vs. $1,755; severe, $2,100 vs. $1,643, all P < 0.001), and a higher likelihood of incurring OA-related costs relative to those without (P < 0.001). CONCLUSIONS: These results provide evidence of the economic impact of opioid use and inadequate pain control by demonstrating that increased pain severity and opioid use in patients with OA were independently associated with higher HRU and costs. Additional studies should confirm causality between opioid use and HRU and costs, taking into consideration underlying OA characteristics. DISCLOSURES: Funding for this study was contributed by Regeneron Pharmaceuticals and Teva Pharmaceutical Industries. Wei is an employee at Regeneron Pharmaceuticals, with stock ownership. Gandhi was an employee at Teva Pharmaceutical Industries, with stock ownership, at the time of this study. Blauer-Peterson and Johnson are employees of Optum, which was contracted to conduct the research for this study.

Health Care Burden Associated with Outpatient Opioid Use Following Inpatient or Outpatient Surgery.

BACKGROUND: The treatment of postsurgical pain with prescription opioids has been associated with persistent opioid use and increased health care utilization and costs. OBJECTIVE: To compare the health care burden between opioid-naive adult patients who were prescribed opioids after a major surgery and opioidnaive adult patients who were not prescribed opioids. METHODS: Administrative claims data from the IBM Watson Health MarketScan Research Databases for 2010-2016 were used. Opioid-naive adult patients who underwent major inpatient or outpatient surgery and who had at least 1 year of continuous enrollment before and after the index surgery date were eligible for inclusion. Cohorts were defined based on an opioid pharmacy claim between 7 days before index surgery and 1 year after index surgery (opioid use during surgery and inpatient use were not available). To ensure an opioid-naive population, patients with opioid claims between 365 and 8 days before surgery were excluded. Acute medical outcomes, opioid utilization, health care utilization, and costs were measured during the post-index period (index surgery hospitalization and day of index outpatient surgery not included). Predicted costs were estimated from multivariable log-linked gamma-generalized linear models. RESULTS: The final sample consisted of 1,174,905 opioid-naive patients with an inpatient surgery (73% commercial, 20% Medicare, 7% Medicaid) and 2,930,216 opioid-naive patients with an outpatient surgery (74% commercial, 23% Medicare, and 3% Medicaid). Opioid use after discharge was common among all 3 payer types but was less common among Medicare patients (63% inpatient/43% outpatient) than patients with commercial (80% inpatient/75% outpatient) or Medicaid insurance (86% inpatient/81% outpatient). Across all 3 payers, opioid users were younger, were more likely to be female, and had a higher preoperative comorbidity burden than nonopioid users. In unadjusted analyses, opioid users tended to have more hospitalizations, emergency department visits, and pharmacy claims. Adjusted predicted 1-year post-period total health care costs were significantly higher (P< 0.001) for opioid users than nonopioid users for commercial insurance (inpatient: $22,209 vs. $14,439; outpatient: $13,897 vs. $8,825), Medicare (inpatient: $31,721 vs. $26,761; outpatient: $24,529 vs. $15,225), and Medicaid (inpatient: $13,512 vs. $9,204; outpatient: $11,975 vs. $8,212). CONCLUSIONS: Filling an outpatient opioid prescription (vs. no opioid prescription) in the 1 year after inpatient or outpatient surgery was associated with increased health care utilization and costs across all payers. DISCLOSURES: Funding for this study was provided by Heron Therapeutics, which participated in analysis and interpretation of data, drafting, reviewing, and approving the publication. All authors contributed to the development of the publication and maintained control over the final content. Brummett is a paid consultant for Heron Therapeutics and Recro Pharma and reports receipt of research funding from MDHHS (Sub K Michigan Open), NIDA (Centralized Pain Opioid Non-Responsiveness R01 DA038261-05), NIH0DHHS-US-16 PAF 07628 (R01 NR017096-05), NIH-DHHS (P50 AR070600-05 CORT), NIH-DHHS-US (K23 DA038718-04), NIH-DHHS-US-16-PAF06270 (R01 HD088712-05), NIH-DHHS-US-17-PAF02680 (R01 DA042859-05), and UM Michigan Genomics Initiative and holding a patent for peripheral perineural dexmedetomidine. Oderda is a paid consultant for Heron Therapeutics. Pawasauskas is a paid consultant to Heron Therapeutics and Mallinckrodt Pharmaceuticals. England and Evans-Shields are employees of Heron Therapeutics. Kong, Lew, Zimmerman, and Henriques are employees of IBM Watson Health, which was compensated by Heron Therapeutics for conducting this research. Portions of this work were presented as a poster at the AMCP Managed Care and Specialty Pharmacy Annual Meeting 2019; March 25-28, 2019; San Diego, CA.

Factors associated with costs and health outcomes in patients with Back and leg pain in primary care: a prospective cohort analysis.

BACKGROUND: There is limited research on the economic burden of low back-related leg pain, including sciatica. The aim of this study was to describe healthcare resource utilisation and factors associated with cost and health outcomes in primary care patients consulting with symptoms of low back-related leg pain including sciatica. METHODS: This study is a prospective cohort of 609 adults visiting their family doctor with low back-related leg pain, with or without sciatica in a United Kingdom (UK) Setting. Participants completed questionnaires, underwent clinical assessments, received an MRI scan, and were followed-up for 12-months. The economic analysis outcome was the quality-adjusted life year (QALY) calculated from the EQ-5D-3 L data obtained at baseline, 4 and 12-months. Costs were measured based on patient self-reported information on resource use due to back-related leg pain and results are presented from a UK National Health Service (NHS) and Societal perspective. Factors associated with costs and outcomes were obtained using a generalised linear model. RESULTS: Base-case results showed improved health outcomes over 12-months for the whole cohort and slightly higher QALYs for patients in the sciatica group. NHS resource use was highest for physiotherapy and GP visits, and work-related productivity loss highest from a societal perspective. The sciatica group was associated with significantly higher work-related productivity costs. Cost was significantly associated with factors such as self-rated general health and care received as part of the study, while quality of life was significantly predicted by self-rated general health, and pain intensity, depression, and disability scores. CONCLUSIONS: Our results contribute to understanding the economics of low back- related leg pain and sciatica and may provide guidance for future actions on cost reduction and health care improvement strategies. TRIAL REGISTRATION: 13/09/2011 Retrospectively registered; ISRCTN62880786 .

Clinical and Economic Analysis of Morphine Versus Fentanyl in Managing Ventilated Neonates With Respiratory Distress Syndrome in the Intensive Care Setting.

PURPOSE: Morphine and fentanyl opioids are common analgesic agents for consideration in the neonatal intensive care unit (NICU) for neonates with respiratory distress syndrome (RDS) and undergoing mechanical ventilation (MV). The aim of this study was to evaluate the clinical and economic impact of morphine versus fentanyl in neonates with RDS undergoing MV. METHODS: Retrospective cost-effectiveness analysis of critically ill neonates with RDS receiving standard doses of morphine versus fentanyl at Women's Wellness and Research Center, Qatar. Clinical data of neonates were extracted from medical records of patients from 2014 to 2016. A decision analytic model based on the hospital's perspective was constructed to follow possible consequences of the initial dosing of analgesia, before potential titration. Primary end points were successful pain relief rate based on the Premature Infant Pain Profile scale and overall direct medical cost of therapy. Study population of 126 neonates was used to achieve results with 80% power and 0.05 significance. Sensitivity analysis was conducted to enhance robustness of conclusions against input uncertainties and to increase generalizability of results. FINDINGS: Morphine achieved a success of 68% versus 43% with fentanyl (risk ratio = 1.72; 95% CI, 1.16-2.56; P = 0.0075). Morphine was associated with a minimal incremental cost-effectiveness ratio of USD 135 per additional case of successful pain relief over fentanyl. Higher morphine cost was reported in 2% of cases. Sensitivity analysis found model insensitivity to input uncertainties except NICU stay and cost of MV. IMPLICATIONS: This is the first cost-effectiveness evaluation of morphine versus fentanyl in the NICU. Morphine significantly improved the relieve of pain over fentanyl. It had 98% probability of dominance over fentanyl. Results in this study support the use of morphine over fentanyl as first-line monotherapy with MV in NICU settings.

Relationship between preoperative patient-reported outcomes and hospital length of stay: a prospective cohort study of general surgery patients in Vancouver, Canada.

OBJECTIVES: As an aging population drives more demand for elective inpatient surgery, one approach to reducing length of stay is enhanced evaluation of patients' preoperative health status. The objective of this research was to determine whether patient-reported outcome measures collected preoperatively can identify patients at risk for longer lengths of stay. METHODS: This study was based on a prospectively recruited cohort of patients who were scheduled for elective inpatient general surgery in Vancouver, Canada. All participants completed a number of patient-reported outcome measures preoperatively, including the EQ-5D for general health status, the Patient Health Questionnaire (PHQ-9) for depression, and the pain intensity (P), interference with enjoyment of life (E), and interference with general activity (G), known as the PEG, for pain. Patient-reported outcome data were linked to hospital discharge summaries. Multivariate regression was performed to estimate risk of longer lengths of stay, adjusting for patient and clinical characteristics. The primary outcome was length of stay and its associated cost. Data collection took place between October 2012 and November 2016. RESULTS: Participation among the population of 2307 eligible patients was 50.5%, providing 1165 participants. Preoperative patient-reported outcomes were not concordant with hospital reported diagnoses of depression or pain. Patients' preoperative depression and pain scores were independently positively associated with longer length of stay after adjusting for patient-level characteristics. Patients whose PHQ-9 score was 10, representing clinically significant depression, were estimated to have a 1.53 day longer hospitalization, which was associated with an estimated incremental hospital cost of $1667. CONCLUSIONS: Preoperative self-reported assessment of depression and pain can assist with identifying patients at higher risk of longer lengths of stay. Patient's self-reported preoperative measures of depression and pain should be incorporated into patient pathways. They provide opportunities for improving management of general surgery patients and possibly play a role in aligning hospital funding with patients' needs.

The Socioeconomic Burden of Pain From War.

War's burden on the health and well-being of combatants, civilians, and societies is well documented. Although the examination of soldiers' injuries in modern combat is both detailed and comprehensive, less is known about war-related injuries to civilians and refugees, including victims of torture. The societal burden of war-related disabilities persists for decades in war's aftermath. The complex injuries of combat survivors, including multiple pain conditions and neuropsychiatric comorbidities, challenge health care systems to reorganize care to meet these survivors' special needs.We use the case study method to illustrate the change in pain management strategies for injured combat survivors in one national health system, the US Department of Veterans Affairs (VA). The care of veterans' disabling injuries suffered in Vietnam contrasts with the care resulting from the VA's congressional mandate to design and implement a pain management policy that provides effective pain management to veterans injured in the recent Middle East conflicts.The outcomes-driven, patient-centric Stepped Care Model of biopsychosocial pain management requires system-wide patient education, clinician training, social networking, and administrative monitoring. Societies are encouraged to develop their health care system's capacity to effectively respond to the victims of warfare, including combatants and refugees.

Four-year review of presenteeism data among employees of a large United States health care system: a retrospective prevalence study.

BACKGROUND: Historically, in an effort to evaluate and manage the rising cost of healthcare employers assess the direct cost burden via medical health claims and measures that yield clear data. Health related indirect costs are harder to measure and are often left out of the comprehensive overview of health expenses to an employer. Presenteeism, which is commonly referred to as an employee at work who has impaired productivity due to health considerations, has been identified as an indirect but relevant factor influencing productivity and human capitol. The current study evaluated presenteeism among employees of a large United States health care system that operates in six locations over a four-year period and estimated loss productivity due to poor health and its potential economic burden. METHODS: The Health-Related Productivity Loss Instrument (HPLI) was included as part of an online Health Risk Appraisal (HRA) administered to employees of a large United States health care system across six locations. A total of 58 299 HRAs from 22 893 employees were completed and analyzed; 7959 employees completed the HRA each year for 4 years. The prevalence of 22 specific health conditions and their effects on productivity areas (quantity of work, quality of work, work not done, and concentration) were measured. The estimated daily productivity loss per person, annual cost per person, and annual company costs were calculated for each condition by fitting marginal models using generalized estimating equations. Intra-participant agreement in reported productivity loss across time was evaluated using κ statistics for each condition. RESULTS: The health conditions rated highest in prevalence were allergies and hypertension (high blood pressure). The conditions with the highest estimated daily productivity loss and annual cost per person were chronic back pain, mental illness, general anxiety, migraines or severe headaches, neck pain, and depression. Allergies and migraines or severe headaches had the highest estimated annual company cost. Most health conditions had at least fair intra-participant agreement (κ ≥ 0.40) on reported daily productivity loss. CONCLUSIONS: Results from the current study suggested a variety of health conditions contributed to daily productivity loss and resulted in additional annual estimated costs for the health care system. To improve the productivity and well-being of their workforce, employers should consider presenteeism data when planning comprehensive wellness initiatives to curb productivity loss and increase employee health and well-being during working hours.

The impact of opioid analgesic prescription uptake on the costs of recovery from injury: Evidence from compensable orthopaedic road trauma patients.

Long-term opioid prescribing after compensable orthopaedic injury may contribute to the 'long right tail' in the cost of recovery. The aim of this study was to estimate the effect of prescription opioid uptake on injury compensation cost, using orthopaedic road traffic injury claims data from Victoria, Australia. We used a maximum likelihood estimation that accounts for potential endogeneity associated with opioid uptake, utilizing information on the doctor's differential propensity to prescribe opioids when treating other compensable injury patients. Our results suggest that opioid recipients incurred significantly greater hospital costs, income compensation payments, and medical and paramedical expenses. Overall, income compensation was the primary driver of the claim cost difference between opioid recipients and non-recipients. The findings imply that there is scope to impose restrictions on long-term opioid usage, and to encourage the use of alternative pain relief medicines.

General Practitioners Referring Adults to MR Imaging for Knee Pain: A Randomized Controlled Trial to Assess Cost-effectiveness.

Purpose To determine the cost-effectiveness of early referral by the general practitioner for magnetic resonance (MR) imaging compared with usual care alone in patients aged 18-45 years with traumatic knee symptoms. Materials and Methods Cost-utility analysis was performed parallel to a prospective multicenter randomized controlled trial in Dutch general practice. A total of 356 patients with traumatic knee symptoms were included from November 2012 to December 2015 (mean age, 33 years ± 8 [standard deviation]; 222 men [62%]). Patients were randomly assigned to usual care (n = 177; MR imaging was not performed, but patients were referred to an orthopedic surgeon when conservative treatment was unsatisfactory) or MR imaging (n = 179) within 2 weeks after injury. Main outcome measures were quality-adjusted life years (QALYs) and costs from a healthcare and societal perspective. Multiple imputation was used for missing data. The Student t test was used to assess differences in mean QALYs, costs, and net benefits. Results Mean QALYs were 0.888 in the MR imaging group and 0.899 in the usual care group (P = .255). Healthcare costs per patient were higher in the MR imaging group (€1109) than in the usual care group (€837) (P = .050), mainly due to higher costs for MR imaging, with no reduction in the number of referrals to an orthopedic surgeon in the MR imaging group. Conclusion MR imaging referral by the general practitioner was not cost-effective in patients with traumatic knee symptoms; in fact, MR imaging led to more healthcare costs, without an improvement in health outcomes.